Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
J19 Physical Plant and Environment
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J20-Construction-The clinic is constructed, arranged, and maintained to ensure access to and safety of patients, and provides adequate space for the provision of direct services.
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J21-Maintenance--The clinic has a preventative maintenance program to ensure that:
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J22-All essential mechanical, electrical and patient-care equipment is maintained in safe operating condition
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J23-Drugs and biologicals are appropriately stored
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J24-The premises are clean and orderly
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J25-Emergency procedures-The clinic assures the safety of patients in case of non-medical emergencies by:
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J26-Training staff in handling emergencies
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J27-Placing exit signs in appropriate locations
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J28-Taking other appropriate measures that are consistent with the particular conditions of the area in which the clinic is located.
J29 Organizational Structure
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J31-The clinic is under the medical direction of a physician, and has the health care staff that meets the requirements of 481.8
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J32-The organization's policies and its lines of authority and responsibilities are clearly set forth in writing.
J37 Staffing and Staff Responsibilities
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J39-The clinic has a health care staff that includes one or more physicians and one or more physician's assistants or nurse practitioners.
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J40-The staff, i.e., the nurse practitioner(s), physician(s), or physician's assistant(s) meets the qualification requirements in section 481.2(b), (c), (d).
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J41-A physician, nurse practitioner, or physician's assistant is available to furnish patient care services at all times during the clinic's regular hours of operation. A nurse practitioner or a physician's assistant is available to furnish patient care services during at least 60% of the clinic's regular hours of operation.
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J42-The staff is sufficient to provide the services essential to the operation of the clinic.
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J46-The physician provides medical direction for the clinic's health care activities and consultation for, and medical supervision of the health care staff.
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J47-In conjunction with the physician's assistant and/or nurse practitioner member(s), the physician participates in developing, executing and periodically reviewing the clinic's written policies and the services provided to Federal program patients.
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J48-The physician periodically reviews the clinic's patient records, provides medical orders, and provides medical care services to the patients of the clinic.
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J49-A physician is present for sufficient periods of time, at least once in every 2 week period (except in extraordinary circumstances), to provide the medical direction, medical care services, consultation and supervision described in paragraph(b)(1) of this section, and, is available through direct telecommunication for consultation, assistance with medical emergencies, or patient referral. The extraordinary circumstances are documented in the records of the clinic.
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J51-The physician's assistant and the nurse practitioner members of the clinic's staff:<br>(i) participate in the development, execution and periodic review of the written policies governing the services the clinic furnishes<br>(ii) provide services in accordance with those policies<br>(iii) arrange for, or refer patients to, needed services that cannot be provided at the clinic<br>(iv) assure that adequate patient health records are maintained and transferred as required when patients are referred<br>(v) participate with physician in a periodic review of the patients' health records.<br>
J52 Provision of Services
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J53-The clinic is primarily engaged in providing outpatient health services as described in 481.9(c)
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J55-The clinic's health care services are furnished in accordance with appropriate written policies which are consistent with applicable State law.
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J56-The policies are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician's assistants or nurse practitioners. At least one member of the group is not a member of the clinic's staff.
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J57-The policies include:<br>(i) a description of the services the clinic furnishes directly and those furnished through agreement or arrangement<br>(ii) guidelines for the medical management of health problems which include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the clinic<br>(iii) rules for the storage, handling, and administration of drugs and biologicals.
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J58-These policies are reviewed at least annually by the group of professional personnel required under (b)(2) above in this section, and reviewed as necessary by the clinic.
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J60-The clinic staff furnishes those diagnostic and therapeutic services and supplies that are commonly furnished in a physician's office or at the entry point into the health care delivery system. These include medical history, physical examination, assessment of health status, and treatment for a variety of medical conditions.
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J61-Laboratory-The clinic provides basic laboratory services essential to the immediate diagnosis and treatment of the patient, including:<br>(i) chemical examinations of urine by dipstick or tablet methods or both (including urine ketones)<br>(iii) hemoglobin or hematocrit<br>(iv) blood sugar<br>(vi) examination of stool specimens for occult blood<br>(vii) pregnancy tests<br>(viii) primary culturing for transmittal to a certified laboratory
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J62-Emergency-The clinic provides medical emergency procedures as a first response to common life-threatening injuries and acute illness, and has available the drugs and biologicals commonly used in life saving procedures, such as analgesics, anesthetics (local), antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids.
J66-Patient health records
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J68-The clinic maintains a clinical record system in accordance with written policies and procedures.
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J69-A designated member of the professional staff is responsible for maintaining the records and for ensuring that they are completely and accurately documented, readily accessible, and systematically organized.
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J70-For each patient receiving health care services, the clinic maintains a record that includes, as applicable:<br>(i) identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient<br>(ii) Reports of physical examinations, diagnostic and laboratory test results, and consultative findings<br>(iii) all physician's orders, reports of treatments and medications and other pertinent information necessary to monitor the patient's progress<br>(iv) signatures of the physician or other health care professional.
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J72-The clinic maintains the confidentiality of record information and provides safeguards against loss, destruction or unauthorized use.
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J73-Written policies and procedures govern the use and removal or records from the clinic and the conditions for release of information.
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J74-The patient's written consent is required for release of information not authorized by law.
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J75-The records are retained for at least 6 years from date of last entry, and longer if required by State statute.
J76-Program evaluation
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J77-The clinic carries out, or arranges for, an annual evaluation of its total program.
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J78-The evaluation includes review of:
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J79-the utilization of clinic services, including at least the number of patients served and the volume of services
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J80-a representative sample of both active and closed clinical records
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J81-the clinic's health care policies
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J82-The purpose of the evaluation is to determine whether:
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J83-the utilization of services was appropriate
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J84-the established policies were followed
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J85-any changes are needed
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J86-The clinic staff considers the findings of the evaluation and takes corrective action if necessary.
Infection Control
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Hand hygiene products (water and waterless) available for staff?
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Healthcare worker appropriate hand lotion available?
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Fingernails natural, only 1/4 inch tip
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Sharps and other waste disposal appropriate.
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Cough etiquette, mask use if possibly infected (patients and visitors).
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Separation of clean and dirty.
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REUSABLE ITEMS: Room cleaning of non-critical items (intact skin contact only) when visibly soiled and at least daily (e.g. BP cuffs, temporal thermometers, computer keyboards, stethoscopes), toss phlebo tourniquets when visibly soiled and at least daily
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Between patient disinfection of point of care testing equipment.
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Disinfectant wet time per manufacturer's label, wear PPE to clean.
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Bathrooms will be monitored for cleanliness.
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Do not re-use items labeled for single patient use.
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High level disinfection-Use of Cidex OPA
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Refrigerator temps, vaccine storage.
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Toy cleaning and books.
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Storage of supplies/managing outdates.
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Does clinic use Dremel for foot care?
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Does the clinic have Liquid Nitrogen, oxygen, or nitrous oxide?
